Discussion on the law that applies to or affects Australia's emergency services and emergency management, by Michael Eburn, PhD and Barrister.

Paying for ambulance services

We’ve recently been having a discussion on informed consent. Not, as you would think on treatment consent, rather financial consent.

Our question is: are there any obligations on an ambulance paramedic to provide information to a patient/relative on the financial implications of their transport to hospital?

All ambulance services charge in some form or another, and we believe that it would be an interesting situation for a patient to receive a bill then argue they weren’t adequately informed about the costs of their treatment and transport – and thus refuse to pay. At the extreme this could even been brought further back to the call taker stage – where a number of services now charge for turning up. Should despatchers advise callers that the call out fee for ambulance assessment is $x?

According to the Australian Consumer Law (set out as Schedule 2 to the Competition and Consumer Act 2010 (Cth)) ‘unsolicited services means services supplied to a person without any request made by the person or on his or her behalf’ (s 2). A person must not assert a right to be paid for unsolicited services (s 40). Further a term of a standard contract that is ‘unfair’ is void (s 23).

If a person rings for an ambulance they are clearly making a request for that service, as they would be if someone rings on their behalf, eg when a friend says ‘you’re not well, do you want me to call an ambulance for you’. Often a person will not ring an ambulance for themselves, either they are not capable of doing so or, even if they are competent, someone else rings without their knowledge.

Consider, for example, a shopkeeper who sees an accident outside his or her store and who immediately rings triple zero without the consent or knowledge of the people involved in the accident. A person who was involved in the accident may have some minor injuries including a laceration on the arm. They are approached by a paramedic who asks ‘Are you OK?’ The person says ‘yes’ but the paramedic offers to check them out. They do an examination, perhaps take a BP and pulse and put a bandage on the cut and say ‘You’re OK, no need to go to hospital, we’ll leave you to it’. That person later receives a bill for Emergency attendance fees – no transport $481.00’ (see http://www.ambulance.vic.gov.au/About-Us/Fees.html). In this scenario, they didn’t ring for an ambulance or even ask for the service, but a paramedic was on scene, offered to check them out. Most people would feel some moral pressure to accept what appears to be an offer of concern from a uniformed member of Australia’s most trusted profession. But they may take a different view if they were told ‘Do you want me to check you out, but it will cost $481 if I do?’

Ethically one would have to say there is an obligation to warn a person that the service they are about to engage attracts a fee but there are no doubt difficulties with that. One would not want to discourage a person from receiving care that they actually needed just because they couldn’t afford to pay for it, and one would hope that an ambulance service would not pursue recovery from a truly indigent person who needed their services. Equally there are problems with asking the call taker to advise the caller of ambulance fees, the caller may not be the person who needs the service and one would not want to discourage people calling an ambulance when they need it or when someone else needs it.

Legally, it is unlikely that the Australian Consumer Law would apply. An ambulance service I would suggest, is not engaged in trade or commerce (but see ‘United Firefighters Union of Australia (‘UFU’) v Country Fire Authority (‘CFA’) [2014] FCA 17 (31 January 2014) and the discussion on why the CFA was found to be engaging in ‘trade’ when providing road crash services; it’s certainly not impossible that they are engaged in trade and commerce) and the right to payment is not because of any alleged contract but because of an operation of law. If we limit our discussion to Victoria then the Secretary of the Department of Health may set fees that an ambulance service may charge (Ambulance Services Act 1986 (Vic) s 10(5)) and the ambulance service must comply with the Secretary’s direction (s 10(6)). An ambulance service (remembering Ambulance Service Victoria is a umbrella title covering a number of separate ambulance services; ss 3 and 23, Schedule 1) may charge reasonable fees for the provision of its services (s 16) and by implication what is a reasonable fee is a fee that complies with the Secretary’s direction under s 10. So this is not an issue of contract (and therefore the provision regarding an unfair contract term can’t apply) and the fee is charged because the Act says it may, or even given s 10(6), must be charged.

Although I don’t think the Consumer Law would apply, given the amount involved will be relatively small and well within the jurisdiction of a small claims court or tribunal, I’d suggest to someone seeking advice in the circumstances I’ve described above, that they may like to go before the relevant tribunal (in Canberra that would be the Australian Capital Territory Civil and Administrative Tribunal) and seek an order to the effect the imposition of the fee is ‘unfair’ and should not be enforced. These small tribunals are relatively cheap, act with informality and try to do justice between the parties rather than focus on the letter of the law; a tribunal member may well be attracted to the idea that the fee is unfair and could with some imagination I’m sure, find that they had jurisdiction and authority to refuse to enforce the debt even if an appeal court might say that this was not a correct application of the law. On the other hand, if the person had been in a life threatening situation and the paramedics saved their life, I don’t think any tribunal member would be attracted to the argument that there was any unfairness, particularly if because of the patient’s condition the paramedics couldn’t explain there was a fee even if they wanted to, and no doubt would have provided the service in any event rather than leave the poor patient to die. In those circumstances, if the person really couldn’t pay one would try to negotiate with the ambulance service to reduce or waive the fee, or accept payment by instalments. If the patient had the means to pay but simply didn’t want to then I think Ray Hadley’s approach, above, is probably appropriate.

20 thoughts on “Paying for ambulance services”

I have been concerned about this issue for some time. In my experience, most paramedics do not raise the question of cost because their focus is, rightly, on provision of clinical care. The scenario mentioned in the blog, however, is quite common: an ambulance crew attends a scene and assesses a person with minor or no injuries, and then asks for personal details for the case record. This is all acting in accordance with the employer’s instructions, however at no stage is the person informed that by accepting even a cursory assessment and by giving their details they will be charged what many might regard as a hefty fee.

The general public is still largely unaware that ambulance services in most states are not free, and many don’t even know what organization runs the ambulance service. While it may be reasonable to presume they would know there would be some charge for a service, I doubt many would have any idea what the amount might be.

Informed consent now forms an important part of ambulance practice (or it should) and I believe patients should have information regarding costs in the same way they are informed about risks of medical procedures.

I recently had a police officer call an ambulance for me after I asked them not to. I specifically said no, because I can’t afford that. The officer said I would not be charged because they had called them.
I have just received a bill for over $1700.

Hi Meg! I have had the same thing happen to me recently as well. I was fully conscious and specifically asked them not to call the ambulance, as did my guardian. They called anyway and neither the officers or the paramedics explained any of the associated costs. I was unaware that I’d even be charged as it did not transport me anywhere. They took my vitals for about 10mins (the police had driven by as I’d had a mild asthma attack) and sent me home. Now I have a bill I cannot afford!
Have you made any progress? Could anyone offer advice?

I agree with Malcolm, particularly the aspect of Paramedics not raising the issue of costs at the time of treatment unless specifically asked. In the ACT the cost of medical checks or transport undertaken at car accidents are covered by the Road rescue fee for ACT residents and this helps eliminate patient costs for roadside observations and examination without transport.

I believe that ambulance services should provide their staff with a small printed card listing a breakdown of fees. The card can be handed to anyone enquiring about costs thus preventing any miscommunication or confusion. A suitable bold disclaimer and contact phone number on the card should also state that paramedics cannot alter or strike off compulsory fees for service. This would fully inform the patient and also help to alleviate bill-shock after the event.

As a NSW RFS volunteer firefighter we were in the field when one of our members twisted his ankle. A relatively minor issue with Rest, Ice, Compression, and Elevation being the only treatment required. An ambulance had been deployed to the location and was on standby.
After a look the ambulance officers agreed with the treatment but offered him a ride back in the ambulance as it was less bumpy than the fire tanker and better air conditioned. He was most surprised to receive a bill for treatment and transport. It took many letters and calls to sort it out.

Ambulance services should be covered by Medicare. If I am unable to provide consent, then I should not be billed for the service. What happens when a family member dies en route to hospital. Do the ambulance service then bill the family. That would be the equiv. Of funeral costs in some circumstances. In QLD the costs are incl. In electricity bill. This should be rolled out across the country so innocent victims of unauthorised treatment are not unfairly billed.

That is interesting. I had not noted, before, s 53B of the Ambulance Service Act 1991 (Qld) which provides that a person ‘whose principal place of residence is in Queensland’ is exempt from paying ambulance fees for services provided by Queensland Ambulance. Further Queensland Ambulance will meet the costs of ambulance services provided to Queensland residents when they are interstate – see https://www.qld.gov.au/emergency/emergencies-services/interstate-ambulance-treatment.html. I’m not sure if there is a levy with the electricity bill (see Community Ambulance Cover Levy Repeal Act 2011 (Qld)) but whether there is or is not, that’s a generous position of the Qld Government.

Queensland recently dropped the levy on their electricity bills, and the state covers the free service, but it is for Queensland residents only. If you are an interstate visitor, you will be billed 100% of the applicable services fees. In this instance you would forward your account to your state ambulance scheme (where they still might exist) or your health fund. Where you are not covered by a health fund, you will then personally owe the cost.

Thabks Jason, as the other comments here show, the levy was dropped in 2011. If the levy was in place the potential constitutional issue (also discussed in the comments) wouldn’t arise as the ‘disability or discrimination’ (ie the exemption from ambulance fees) would not be based on the state of residence but on whether or not the person was liable to leave pay a levy.

John, an exemption from fees based on state of residence may be unconstitutional if the Commonwealth did it (Australian Constitution, s 117) but states can make their own arrangements. Ambulance service are state based services so one state can chose to offer the service for free or collect a levy whilst others can make direct charges. We’ve seen differences in how fire services are funded (an insurance levy v property tax), registration and licence charges vary from state to state etc. It’s not the case that the Commonwealth sets ambulance fees and then exempts Queenslanders or that Queensland is paying the Commonwealth on behalf of its residents. Ambulance fees have nothing to do with the Commonwealth so I can’t see that the Constitution has anything to say on the matter.

Fair point- certainly s 117 does limit the power of the states to discriminate on the basis of residence and I have looked at the cases you have mentioned (Street v Queensland Bar [1989] HCA 53 and Sweedman v TAC [2006] HCA 8) and I can see the point that making the exemption based on residence may be contrary to s 117. It would appear that this would be avoided if Queenslanders did pay a contribution or levy for ambulance services but that has been scrapped. On 29 August 2012 Bridie Jabour of the Brisbane Times, in her article ‘Newman scrambles after ambulance levy stumble‘, reported:

Between July 1, 2003, and June 30, 2011, the Community Ambulance Cover levy was charged on electricity bills in Queensland to help fund the Queensland Ambulance Service.
The levy was scrapped from July 1 last year, when the full cost of the ambulance service was funded through the state government budget.

In Street v Queensland Bar, Mason CJ said (at [35]) “In Davies and Jones, O’Connor J. stated (at p 53) that s.117 “does not prohibit a State from conferring special privileges upon those of its own people who, in addition to residence within the State, fulfil some other substantial condition or requirement”. It is implicit in that statement that a privilege granted upon the basis of residence alone may offend s.117.’ The exemption from ambulance fees appears to be based upon residence alone, not residence and payment of a levy or some other qualifying condition. So it would indeed appear to be arguable that this clause is unconstitutional.

I’m not a constitutional lawyer (clearly) but I have to say those cases do cause me to reconsider my earlier answer. Clearly I’m wrong that s 117 only limits the Commonwealth. I’m not sure whether s 53B of the Ambulance Service Act 1991 (Qld) is the sort of ‘… disability or discrimination … contemplated as falling within the proscription in s.117’ (Street v Queensland Bar, Mason CJ, [35])). Fortunately I work at the ANU with some leading constitutional lawyers, so I’ll ask for a second opinion and get back to you.

I said I would get a ‘second opinion’ on this one, so I approached my colleague Associate Professor Amelia Simpson, an expert on constitutional law and constitutional rights. She said:

That’s an interesting question. Thanks for the invitation to consider.

While it’s far from a no-brainer, my instinct is that this Qld provision would probably survive a s 117 challenge. This is because it seems fair (based on what you’ve provided here, at least) to characterise it as a form of welfare benefit for Qld residents – paid for with Qld public funds – rather than as a protectionist measure to exclude competition from interstate in some commercial or professional context.

The decision in Street … turned on assessments of reasonableness channelled through a proportionality test. This was against the background of an acceptance that the purpose of s 117 is to foster a sense of national unity, but that that goal must be balanced against States’ legitimate interest in preferencing their own in the provision of some public goods (some examples were mentioned in a couple of the Street judgments – eg public housing).

This ambulance instance is, to my mind, closer to the discussion of public housing, etc, than it is to the regulation invalidated in Street, which involved bald protectionist discrimination.

So the best answer I can give, thanks to Amelia, is that s 53B is probably constitutional, but if someone who resides outside Queensland receives a bill from Queensland ambulance and wants to challenge it, there’s an opportunity to try to get to the High Court!

Thanks for the answer Michael.
My first response was really aimed at triggering some thought on state-of-residence discrimination and s 117.
My second just on pointing out that your initial response was clearly not well thought through.
It is an interesting and tricky area and one that has not yet had strong judicial treatment. I remember as a young man going to Victoria and being denied a concession train fare because I lived in WA. At the time I felt aggrieved, but it was not until some time later I found it may have been illegal.
However, as your friend points out – notwithstanding the clear prohibition in the Constitution the High Court may well find it to be reasonable given the State’s subsidy of transport services. I find this unsatisfactory. Any state legislation conferring a state of residence based exemption flies in the clear face of s. 117 and is therefore ineffective.
s. 117 is quite clear in its language and does not easily accommodate a ‘reading down’.
Anyway – just one of my little bugbears.

A friend recently had a bad blood nose that would not stop.
My friend’s Mother called for an ambulance as the caller was too weak to drive due the chemo therapy treatment.
The jurisdiction is St John Ambulance W.A. As St John is a private company, with the 000 contract for the state ambulance service.
My friend received a bill for about $900 dollars.
On contact with St John, it would seem if you don’t pay on time, the bill is handed to a debt collector.
The call receiver can decide on any priority classification they wish.
It would see there is no redress on ambulance fees.

My original post was in response to a question from Victoria. In Victoria the right to charge fees is set out in statute – Ambulance Services Act 1986 (Vic) s 10. There’s no similar statute in WA and given St John is a private contractor rather than a state instrumentality it would be easier to argue that they are engaged in trade and commerce and that the Australian Consumer law applies to them. I wonder if anyone has challenged the right of St John Ambulance (WA) to render a bill particularly where the person in need of care is unable to consent to treatment.